Healthcare Provider Details

I. General information

NPI: 1528031473
Provider Name (Legal Business Name): ANDREA M HOLTHAUS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2006
Last Update Date: 06/22/2021
Certification Date: 06/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3009 N BALLAS RD STE 383C
SAINT LOUIS MO
63131-2324
US

IV. Provider business mailing address

3009 N BALLAS RD STE 383C
SAINT LOUIS MO
63131-2324
US

V. Phone/Fax

Practice location:
  • Phone: 314-996-4545
  • Fax:
Mailing address:
  • Phone: 314-996-4545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number2004011870
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number2004011870
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2004011870
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: